Upper Extremity Positioning

Finger Exam

A routine finger exam consists of three images: PA, Oblique, and Lateral. The central ray for all three views are the same: 40" perpendicular to PIP joint. You should be able to visualize soft tissue around the finger, as well as all relevant anatomy; from the distal phalange to the distal metacarpal of the affected digit. The digit should also be as parallel to the IR as possible, in order to reduce foreshortening of the part. Keep in mind that site protocol may require anatomy down to the carpal region as well.

Routine Views:

PA - 40" Perpendicular to PIP joint

Oblique - 40" Perpendicular to PIP joint

Lateral - 40" Perpendicular to PIP joint

Hand Exam

A routine hand exam consists of three images: PA, Oblique, and Lateral. The central ray for the PA and Oblique views are: 40" perpendicular to the 3rd MCP joint. For the Lateral view: 40" perpendicular to the 2nd MCP joint. All relevant anatomy should be visualized, from the distal phalanges to the radial and ulnar styloid processes. The oblique view should not be rotated more than 45 degrees. On the Lateral view, the metacarpals should be superimposed. Most facilities will perform a Fan Lateral, which would minimize superimposition of the digits. For all views, be sure that all digits remain parallel to the IR to avoid distortion.

Routine Views:

PA - 40" Perpendicular to the 3rd MCP joint

Oblique - 40" Perpendicular to the 3rd MCP joint

Lateral - 40" Perpendicular to the 2nd MCP joint

Wrist Exam

A routine wrist exam consists of three images: PA, Oblique, and Lateral. The central ray for all three views are the same: 40" perpendicular to the midcarpal region. For the PA view, have the patient make a loose fist to put the carpals as close to the film as possible. This will minimize distortion. The Oblique view should not be rotated more than 45 degrees. On the Lateral view, a slight over-rotation will allow the pisiform to be viewed in profile.

Routine Views:

PA - 40" Perpendicular to the midcarpal region

Oblique - 40" Perpendicular to the midcarpal region

Lateral - 40" Perpendicular to the midcarpal region

Forearm Exam

A routine forearm exam consists of two images: AP and Lateral. The central ray for all three views are the same: 40" perpendicular to the midforearm. On the AP views, the styloid processes and epicondyles should be parallel to the IR. On the Lateral view, flex the elbow 45 degrees and ensure the styloid processes and epicondyles are perpendicular to the IR. Flexion of the elbow will open the joint spaces in that region. The radius and ulna will be superimposed on the Lateral view.

Routine Views:

AP - 40" Perpendicular to the mid forearm

Lateral - 40" Perpendicular to the mid forearm

Elbow Exam

A routine elbow exam consists of three images: AP, Oblique, and Lateral. The central ray for the AP and Oblique views are the same: 40" perpendicular to the mid-elbow region. For the lateral view: 40" perpendicular to the lateral epicondyle. Be sure the styloid processes and epicondyles are parallel to the IR on the AP view. The routine view for the oblique requires an external rotation. This will show the radial head and neck without superimposition over the ulna. For the lateral view, flex the elbow 45 degrees to open the joint spaces. The epicondyles will be superimposed.

Routine Views:

AP - 40" Perpendicular to the mid elbow

Oblique - 40" Perpendicular to the mid elbow

Lateral - 40" Perpendicular to the lateral epicondyle

Humerus Exam

A routine humerus exam consists of two images; AP and Lateral. The central ray for both are the same: 40" perpendicular to mid-humerus. Both views should be obtained in the upright position. The arm should be abducted slightly, with the hand supinated in the AP view. The epicondyles should also be parallel to the IR. In the Lateral view, the arm should be internally rotated, so that the epicondyles are perpendicular to the IR.

Routine Views:

AP - 40" Perpendicular to mid humerus

Lateral - 40" Perpendicular to mid humerus

Shoulder Exam

A routine shoulder exam consists of three images; Internal, External and Neutral Rotation. The central ray for all views are the same: 40" perpendicular to 1" inferior to the corocoid process. All views should be obtained in the AP projection. Internally rotating the arm will place the lesser tubercle in profile. Supinating the hand will place the greater tublercle in profile. The neutral position will show the greater tubercle partially in profile on the lateral aspect of the humerus.

Acromioclavicular Joints Exam

A routine exam of the AC Joints consists of two AP views. One with weights and one without. The central ray for both images are the same: 40" perpendicular to midline at the level of the AC joints.The view should be obtained in the upright position and including weights. The weights should be attached to the patients wrists, with instructions to allow the shoulders to relax. This will allow proper separation of the AC joints. Both AC joints should be included on the same image.

Routine Views:

AP with weights - 40" Perpendicular to midline at the level of the AC joints

AP without weights - 40" Perpendicular to midline at the level of the AC joint

Clavicle Exam

A routine clavicle exam consists of two images: AP and Lordodic. The central ray for the AP view is 40" perpendicular to mid clavicle. The central ray for the Lordodic view is 40" angled zero to 15 degrees cephalic to mid clavicle. To position for this view, have the patient lean backwards into the upright bucky. Their neck should be in flexion, resting against the bucky along with the shoulders. If the patient is in the supine position, the Lordodic view requires a 15 to 30 degree cephalic angle.

Scapula Exam

A routine scapula exam consists of two images: AP and Scapular Y. The central ray for the AP is 40" perpendicular to 2" inferior to the coracoid process. Position the patient so that the arm is abducted and flexed at 90 degrees to the body. This is the "stop sign" position. For the Scapular Y view, center 40" perpendicular to the medial border of the scapula. Adjust the patient in a RAO or LAO position, with the affected side down. An average of 45 to 60 degree rotation is needed to place the scapula perpendicular to the IR. Unlike a Y view for a shoulder, the humerus should not superimpose the body of the scapula.